A Direct Comparison of Patient Perception of Outcome After Implant Assisted Immediate Breast

A direct comparison of patient perception of outcome after implant assisted immediate breast reconstruction at one and six years post surgery

Darhouse, Nagham MBBS, M.Sc.; Kadayaprath, Geeta M.S., F.R.C.S; Tan, Su-Ming M.Med.(Surg.), F.R.C.S.; Faliakou, Eleni C. M.D.; Choy, Christina F.R.C.S.; A'Hern, Roger M.Sc.; Ward, Ann S.R.N., M.A.; Gui, Gerald P H M.S., F.R.C.S.

Corresponding author: Mr Gerald PH Gui MS FRCS FRCS(Ed), Academic Surgery (Breast Unit), Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom.Telephone: +44 (0)20 7808 2783.Fax: +44(0)2078082673 e-mail:[email protected]

Introduction: Immediate breast reconstruction (IBR) is offered to suitable patients who require mastectomy for cancer treatment. There are few studies that directly address patient perception of outcome in a uniform study group undergoing standardized IBR surgery utilizing a single implant type. The McGhan 150 permanent expander implant is a biodimensional anatomical device with elastometer properties that encourages early tissue cohesion with the potential of achieving a superior breast form at a single stage operation.1,2 We present the results of a consecutive series of patients who had a submuscular implant reconstruction alone or an implant assisted latissimus dorsi flap using the McGhan 150 implant.

Objective: The aim of the present study was to evaluate patient perception one year after IBR and again five years later using the breast cancer quality of life assessment tool QLQBR-23.

Patients & Method: 40 consecutive patients who had undergone IBR mastectomy for early breast cancer using the McGhan 150 implant were prospectively studied at 1 and 6 years post surgery. Standardized surgery was performed under the care of a single consultant surgeon. The mean patient age was 46 (20-76) years and the mean follow-up interval was 53(15-100) months.

A validated modification of the QLQBR-23 breast cancer quality of life outcomes questionnaire was used to measure body image perception, physical effects, cancer worry and surgical choice. The questionnaires were sent to patients to complete in the privacy of their own homes. Patients were also encouraged to provide free text responses of their experience. All data were anonymized and analyzed using Spearman rank correlation and the Stuart-Maxwell test of marginal homogeneity.3

Results: Patient satisfaction was similar after the 1st and 6th year when perception of attractiveness (P=0.456), femininity(P=0.623), difficulty being seen nude by partner(P=0.515) and the effect of surgery on feeling less whole(P=0.823) were considered(Figure 1). n o i t c a f s i t a s

e Figure 1: Average percentage of patient satisfaction by category of response to questionnaire i t st th a at 1 and 6 year p

e 90 g a t n

e 80 c r e p

e 70 g a r e

v 60 A 1st Year

50 6th Year

0 Body image percention Physical Effects Surgical choice Cancer Worry

However, whilst women were generally satisfied with the appearance of their breast, deterioration of the IBR was observed such that there was a greater proportion of dissatisfaction at six years compared with one year (15% vs 35% respectively, P=0.009). The proportion of women who would have chosen a different surgical strategy increased from 18% to 28% at one vs. six years, but this difference was not statistically significant (P=0.099). Cancer worry was unaffected by IBR and was unaffected by longer follow-up, (36% and 25% respectively, P=0.115).

No differences were observed in functional parameters studied relating to physical effects including pain, paraesthesia, loss of pleasurable sensation, bra fitting, arm movement and scars (Figure 2).

Discussion: Overall satisfaction following implant assisted IBR was high and sustained at six years. A greater proportion of women reported subjective dissatisfaction with the appearance of their IBR at six years compared with one year. Multiple parameters are likely to influence patient perception of outcome. Women considering IBR need to be provided with maximum information in order to make an informed decision on their surgical choices to suit individual needs. Figure 2: Comparison of patient responses to individual parameters of the questionnaire at 1st and 6th year

Difficult being seen nude by partner n o i Feeling less feminine t p e c r

e Felt physically less attractive P

a Difficult to look at yourself naked m i

o Dissatisfied w ith appearance of breasts B

Breast surgery has left body less w hole

Loss of pleasurable sensation in breast

Unpleasant feeling of tightness across the chest

Lack of symmetry Year 6 t

c Unacceptable scar e

f Year 1 f E

a Difficulties finding w ell-fitting bras c i s y h

P Restricted arm movement

Feeling of numbness or tingling

Pain in the side of the chest e

c Pain in the treated breast i o l h a e c C c i

o Would you choose a different surgical treatment a r h c u i c r g S y e r y r r c r u r

n o Worried about future health S o a W w

c 0 10 20 30 40 50 60 70 80 90 n a

C Percent of Patients

Conclusion: As patients recovered from oncologic aspects of their cancer care, expectation of their breast reconstruction heightened. IBR did not affect cancer worry but positively empowered women with surgical choice. Patients’ quality of life remained high after long- term follow-up.

References: 1. Gui,GP., Tan SM., Faliakou, EC., Choy, C., A’Hern R., and Ward, A.:Immediate breast reconstruction using biodimensional anatomical permanent expander implants: a prospective analysis of outcome and patient satisfaction; Plast, Reconstr.Surg;111;125;2003

2. Maxwell, GP and Falcone, PA.: Eighty four consecutive breast reconstructions using a textured silicone tissue expander; Plast,Reconstr.Surg;89:1022;1992

3. Everett BS: The analysis of contingency tables, City of London, Chapman & Hall, 1977